29082 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD
ING•ELECTRICAL PERMITNO. ///���/� a
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 2 9 0 /�
8
BUILDING PROJECT IDENTIFICATION N, v V L,
BUILDING ADDRESS: gy''�) - - SANITARY NO. r APPLICATION SUBMITTAL DATE
n
OWN PFW CONTRA 0
L (AJ N/C- CONTROL If
RCHITECT/EN611SMIL ,,LIC NO: ADD¢ w ❑
I411,
PxoNe: - ` BUILDING PERMIT INFO
HONE I �' ❑ Consultant Fees Paid by Applicant(Initial) PLDG ELECT, PLUMB MECH
t r LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm tht 1 am liecnsad nada pmsdslors of chapter 9(commencine JOB DESCRIPTION
ozzuF100 with Section TIDO) furalhouiessand fowi Codean my license is s. RESIDENTIAL:
F W- in full force and effi. PERMIT ISSUANCE •J V ❑SFDWL [I KITCHEN REMODEL
U U License Class ' Fic.p
N�W Da Convector APPLIANCES—RESIDENTIAL ❑ADDITION ❑SPLUMBING TRUCTURAL'F,pl'tjs CHITECTS DECL PANELS ❑MULTI-UNIT' ❑STRUCTURAL^
Z O r�'7a 1 underc be used es oun1'c recoNs - MODIFICATION
OZ-- �/ — UP TO 200 AMPS IEl INTERIOR [I CHIMNEY REPAIR
Ft9 � LicensedPofeev al
OWNER-BUILDER DECLARATION 201-1000AMPS IMPROVEMENT
4 a .. OVER OW AMPS BATH REMODE P rO DEMOLITION
�j 1 hereby affirm that I am exempt from the Contractors License Law for they'
ip5,O 4 U following reason(Section]031.5.Rosiness and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER
W O a which requires a Permit m construct,alter,improve,demolish,or repair any structure' ' -
H� pnort its issuance,also requires the applicant f npemitt fl signed statement' SPECIAL CIRCUIT/MISC. s
p. that heslicensed pursuant the provisions ofthe Contractors License Law(Chapter9
00 (commencing with Section 7000)of Division ofthe Business and Professions Code)or TEMP.METER OR POLE INST. . .. COMMERCIAL:
F p,M f� that he is exempt thererrom and the basis for Ne alleged exemption Any violation of ❑NEW BLDG/ADDITION 0 DEMOLITION
if 4
Seaton 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of, POWER DEVICES
Wl 2 TENANT ❑FOODSERVICE
x�y " - IMPROVEMENT' ., r
y t more than five hundred dollars($500).
'al not
owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will dahe work,and thesl'ucture is not intended or offered for..sale(Sec.0044.Business '' ❑OTHER
and Pmfessiorn Cade:The Contractor's License Law does bol apply to an owner of OUTLETS—SWITCHES—FIXTURES
properly who builds or improvie'decown,and who does such work himself ac through
his own employees,provided that such improvements are not intended or offered for 'NEW RESIDENTIAL ELECTS •SQ FT.
sale.If.however,the building or improvement is sold within one year ofcompletum,the SQ.FTFLOORAREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for put-
pose of sale.). - '
I,as owner of the property,am exclusively contracting with licensed contractors m.l. TOTAL: -
construct die project(Seo.7(A4,Bus and Professions Code:)The Contractor's Li-
ase Law docs not apply to an owner of property who builds or improves thereon,and, QTY. FLUMBIN ERMIT FEE -
whocontractslor such projects with a counteracts)licensed pursuant to the Contractor's
License taw. PERMITISSUANCE
❑ I am exempt under See .B&P C for this reason -
Owner Date ALTER—DRAIN&V WAT JA VALUATION
Wm under
WORKERS COMPENSATION DECLARATION
I hereby,affism under penalty of perjury one of the following dec] s BACK FL OW PROTamtionECT DEV ICE
❑
1,top and will maintain a Certificate of Consenuo self-insure for Worker's Compen- DRAINS—FLOOR,ROOF,AREA COND. STORIES TYPE CONSTRUCTION
action,as provided for by Section 3700 of the Labor Cade,for Ne performance of the
work for which this permit is issued. FIXTURES-PBR TRAP
1 he an will ainmin Worker's Campensition Insurance.es required by Se tion -
' 3]Wo eL or it p o Hance df thew rk h' y;gltpef iQ d. GAS—EA.SYSTEM-1 INC.40UTLE OCC GROUP APN
My W r oro t re
artier and Pol lJII-�(/!/�\J .
Carne Policy N .: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICAT F EXEMPTION FROM WORKERS'
CO ENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR -
(Thls section need no be wangler 1 Olu permit is for onehundred dollars(E 100)- BUILDING DIVISION EBBS
or las) - GREASETRAP PLANCHECK FEE'
I certify that in thepeffso race ofthe work for which this permit is issued,l shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE' "
07.. sation laws of California.Dam WATER HEATER WNENVELECTR' -
z Applicant - GRADING FEE
ry y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you.should WATER SYSTEMITREATING
abecome subject to the Workers Compensation provisions of the Labor Code,you most SOILS FEE'
LTJ forthwith comply with such provisimns dr this permit shall be deemed revoked. WATER SERVICE
LD z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMW SQ.Fr. PAID
V O Ihereby affirmthat there is a conswetion lending agency for the per4nmence of - Dale Receipt#_
the work for which this permit is issued(Sec.3097,Cm C.)
F•' Lender's Name TOTAL:
WLenders Address 'TOTAL
FE
ly I reality that I have read his application and state that the above information is r BUILDING E
V) correct.I agree to comply with all city end county ordinances and state]awe relating to QTY. MECHANICAL PERMIT FEE
U building construction.andhereby aothoriecrepresenmtives ofthis city toentermanthe SEISMIC FEE
above-memmned properly for inspection purposes. PERMIT ISSUANCE•
( )agree t0 save,indemnify and keep harmless the City of Cupertau against' - ELECTRIC FEE ^^�
liabiliti ,jodg.ec tL,'avtsandexpenses which mayin any way accrue against said City ALTER OR ADD TO MECH. - PLUMBING FEE'S
in con. gnenc ft granting of this permit.
APPL ANT N iR -ANDS AND WILLCOMPLY-WI A ,NON-POINT AIR HANDLING UNIT(TO IL000CFM) MECHANICAL FEE � -
.' SOU :ERE L 'I S.
AIR HANDLING UNIT(OVER I0,00)CFM) . CONSTRUCTIONTAX -
Signatu p ma ontractor Dae EXHAUST H006(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE + HOUSING MITIGATION FEE
` Will fleapplicantor future building ocetramu tnrem handle hazardous material HEATING UNIT(TO 100,00(1 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Corp.Section 25532(a)] HEATING UNIT(OVER'100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE REBID) PAID
Will Ne applicant or future building occupant use equipment or devices which -
emit hazafdous air contaminants as defined'by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) ' ,�
Disvictp• Zd
❑Yes' E]No BOILER—COMP(OVER 100,00)BTU) V
I have recd the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER NCE TE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIALMECH. SQ.EL'
building does not currently have'a mount,drat it is my responsibility to notify the occupant
of are reyuirement,which most be met prim m issuance of a CcnmEcatc of Occupancy.
Owner or authorized agent - _ - Dum r TOTAL:
OFFICE a,